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General NPI Number Information
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NPI Number | 1083971212
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Entity Type | Organization
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Legal Business Name | KEVIN PURVIANCE DMD LLC
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Dates
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Enumeration Date | 04/12/2012
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Last Update Date | 04/12/2012
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Provider Practice Location Address
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Address Line | 61 S MAIN ST SUITE 301
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City | WEST HARTFORD
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State | CT
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Zip | 06107-2486
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Country | US
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Telephone | 860-236-2566
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Fax | 860-236-2282
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Provider Business Mailing Address
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Address Line | 61 S MAIN ST SUITE 301
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City | WEST HARTFORD
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State | CT
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Zip | 06107-2486
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Country | US
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Telephone | 860-236-2566
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Fax | 860-236-2282
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEVIN PURVIANCE
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Credential | DMD
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Telephone | 860-256-2566
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 9313
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License Number State | CT
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